THIS INFORMATION IS CONFIDENTIAL AND IS AVAILABLE ONLY TO THE COURT REGISTRATION OF PRIVATE PROFESSIONAL CONSERVATOR (Probate Code §2342) Initial Information Statement Annual Information Statement Date: Name of Conservator: Home Address: Home Phone Number: Business Address: Business Phone Number: Annual Statement: (Registration is required for each year that you wish to practice as a Private Professional Conservator in San Francisco County.) 1. List educational background, professional and work experience. a. College or University: Educational background: Units Completed Semester/Quarter: Major Subject: Degree Earned (Year): Name: Dates Attended: Location: Units Completed Semester/Quarter: Major Subject: b. Dates Attended: Location: College or University: Name: Degree Earned (Year) Work Experience: (Resumes will not be accepted as a substitute for completing this section.) 1. 2. 3. 4. List work history (including military service and applicable volunteer experience) for the last TEN (10) years. Begin with most recent experience. Attach additional sheets, if needed. Explain any gaps between employments. List experience, regardless of date, which relates to being a conservator. Describe duties as completely as possible: If supervisory, list number of employees supervised. If you held more than one position with the same employer, list each separately. American LegalNet, Inc. www.USCourtForms.com (Start with your most recent position.) Name and address of employer: Title and function: Name of Supervisor: Dates of employment: Reason for leaving: Name and address of employer: Title and function: Name of Supervisor: Dates of employment: Reason for leaving: Name and address of employer: Title and function: Name of Supervisor: Dates of employment: Reason for leaving: 2. List at least three professional references: Name 3. Address Phone Relationship List the names of your current conservatees, court location (county) and case number. (Use separate sheet if required.) Name Case Number Court Location (County) American LegalNet, Inc. www.USCourtForms.com 4. List the aggregate dollar value of assets of all conservatees currently under your supervision: ___ 5. ___ Have you as a Conservator ever been removed for cause as a Conservator, or have you resigned as a Conservator in a specific case: YES NO (Check appropriate box.) If yes to above, on a separate sheet of paper, list the circumstances causing that removal or resignation, and the case names, court locations, and case numbers. 6. List case names, court locations, and case numbers of all closed Conservatorship cases in which you served as the Conservator: Name 7. Case Number Court Location (County) Statewide Registry: Certificate of Registration Number: _ _ Date of Certification: _ _; Renewal Date: _ _. Please also enclose any verifying information of the above registration. Both the local county registration and the Statewide Registry are required for a private professional conservator (Prob. C. §2340, 2850). 8. Date of last fingerprinting with the Department of Justice: _ _ CERTIFICATION I hereby certify that all statements made in this certification request are true and complete to the best of my knowledge. I understand that any false, incomplete or incorrect statements may result in my disqualification as a registered private professional conservator. I hereby authorize all my employers to release any and all information concerning me, including information of a confidential or privileged nature. I hereby release any and all employers from any liability or damage, which may result from furnishing the information requested. Date Signature FOR COURT CLERK USE ONLY 1. 2. 3. Yes No Current Statewide Registration Current County Registration: Yes No Fingerprint card was made and forwarded to Dept. of Justice on _ Date Requested: _ _ Date Received: _ _ _ American LegalNet, Inc. www.USCourtForms.com